We read with great interest Drs. Saha and Segal’s recent article  in which they conducted a large, retrospective study evaluating the relationship between intraoperative transitions of anesthesia care and postoperative outcomes, and the ameliorating effect of standardized handoff. As the authors highlight, this study is one of the first to articulate the effect on patient outcomes after the implementation of standardized intraoperative handoff in anesthesia care, as previous studies have instead predominantly described impacts on information-transfer, retention, perceptions, or satisfaction. 

Implementing a new, standardized handoff requires considerable clinician engagement; the authors illustrate a dramatic increase in handoff adoption throughout the 2-yr study period. Can they describe how handoff adoption was encouraged or whether participation was mandated? Further, in a recent systematic review, Riesenberg et al. underscore the importance of clinician education in promoting the behavior change required for the implementation of handoff.  Can the authors discuss what role, if any, education played in the successful adoption of handoff in their study? This information can better inform future handoff quality improvement projects on how best to on-board clinicians on the use of new tools.

Although the authors clearly describe the components of their standardized handoff tool and provide an illustration of the tool integrated into Epic, it is unclear how the components within the tool were selected and which stakeholders were involved in this decision-making. For example, Julia et al., in a similar pre-post study evaluating the impact of intraoperative hand-off in anesthesia care, describe the utilization of the Delphi method to capture consensus between residents and staff, in addition to literature review, to select 23 elements of their implemented handoff checklist.  In contrast, Boat and Spaeth relied on consensus among a quality improvement team of anesthesiologists and nurse anesthetists in selecting components of their handoff tool. Other studies, both within anesthesiology and in other specialties, have adopted nationally standardized handoff tools such as I-PASS (Illness, Patient Summary, Action List, Situational Awareness, Synthesis), instead of creating personalized handoff tools based on staff consensus, as these standardized tools have been extensively studied in multiple settings.7  Will the authors expand on this decision-making process?

We congratulate the authors for conducting such a time-intensive, rigorous study to better understand this important part of anesthesia care. Given the frequency of such intraoperative transitions, often for legitimate reasons like managing provider fatigue, this is clearly an important area of focus for improving the quality and safety of anesthesia care.